Services

Description

Catheter clinics started in Faversham in April 2016 (based at Newton Place), in Whitstable in May (based at Whitstable Medical Practice) and in Canterbury (based at Northgate and Bridge).  Whilst the clinics are practice based they support patients from across the Town localities.

Outcomes so far

Figures for 2017/18 showed a 20% reduction in A&E attendances for catheter related problems.

Referral

Patients can self-refer to access the service: Patient self-present at the surgery where the service is offered.  When the patient is discharged from urology the local hospital notifies the GP surgery where the patient is registered and the patient is informed of support services available within the community.

Description

Local Care Hubs are where professionals including GPs, geriatricians, social care, community nurses, mental health and social prescribers (with others joining where appropriate) work together to look at patients who are at risk of being admitted to hospital. They allow professionals to work together and share information.   There are 5 Local Care Hubs / MDTs; Ash / Sandwich, Canterbury North, Canterbury South, Faversham Medical Practice / Newton Place and Whitstable.

Outcomes so far

Since the launch in October 2016 a total of 2,648 patients had been referred into the service at the end of February 2018.

Referral

Referral is via the LRU/the Health and Social care coordinator/at the MDT.

Description

Two Geriatricians are employed by Kent Community Health Foundation Trust who are MDT facing and attend CHOCs.  One more Geriatrician is being recruited. Geriatricians support medical decision making to keep people well in their own homes.

Referral

A Geriatrician referral can be made via the Local Referral Unit or at the Local Care Hub / MDT.

Monday to Friday 12 noon to 2pm there is a Clinician to Clinician advice and guidance service to discuss frail patients at risk of acute hospital admission in the next week.  The phone number for this service is 0300 1234498.

View the flyer here

The service

Encompass has been working with Age UK to provide drop-in dementia clinics.  The Dementia Services Link Worker started working across the Local Care Hubs in April 2017 providing holistic support for families and carers and signposting to additional support services.

Outcomes so far

Contact has been made with 343 carers, of which 208 requested further involvement up to the end of December 2017.

The majority of referrals are for Carers requesting ongoing one to one advice, information and support.

Referral route

Referral from the acute or through the Local Care Hub /MDT

The service

12 Practitioners have signed learning agreements for GPs with special interest (GPwSI) training.  Encompass has supported this training with matched funding for backfill and course costs. The seven speciality areas include: Dementia,  Dermatology, ENT, Urology, Ophthalmology, Respiratory and Cardiology.

Outcomes so far

The majority of the practitioners commenced training in September 2017. A number of practices offer a GPwSI service and this can be access through the practice and the CCG Referral Support Tool Click here to view.

Canterbury and Coastal CCG have a referral support tool to show which services are provided by whom. To view the tool please visit their website.

The service

Health and Social Care Coordinators support the Local Care Hub MDTs.  They are a key link between the patient and the staff supporting them.

Outcomes so far

Since the launch in October 2016 a total of 2,648 patients had been referred into the service at the end of February 2018.

Referral

Referral is via the Local Referral Unit  at the Local Care Hub /MDT.

The service

Following the pilot at Northgate Medical Practice, Health Trainers were rolled out to Canterbury North, Ash & Sandwich and Faversham from October 2017.  Health Trainers work with clients to develop a personal health plan that suits the individual and set primary goals i.e. weight reduction, stop smoking, physical activity and general health.

Outcomes so far

The Health Trainers have provided a service to 278 clients up to December 2017 with 82% achieving or part achieving their goals.

Referral

Practices can refer directly to the Health trainer aligned to their practice.

The service

Encompass is working with Invicta Health to support self management/admission avoidance for individuals with long term mental health (bi-polar, schizophrenia).

Outcomes so far

The groups have helped individuals to be less isolated by meeting others with a similar diagnosis and have helped them to understand their condition and learn about relapse prevention to enable them to stay well and out of hospital.

Referral

GPs can write a letter or complete a referral form held on the GP system and email to: invictahealth.mentalhealthreferrals@nhs.net

Service
Support the MDT around complex patients involving facilitating discharge, preventing admission and visiting the patient in their own home to optimise their medication.

Outcomes so far
The team attend Local Care Hubs and support patients in the community. The Community Pharmacist Service has been running since August 2017.

Referral

Via the LRU/the Health and Social care coordinator/at the MDT.

The service

Encompass has been working with Red Zebra to develop and build a database of voluntary and community services that service users and practitioners can access.  Red Zebra started attending the Local Care Hubs in July 2016.

Outcomes so far

548 patients have been referred for social prescribing up to February 2018.  The highest reason continues to be social isolation followed by health condition and career needs.

Referral

The service can be accessed by the social prescribing team through the Connect Well Kent website and through the Local Care Hub / MDT.

The service

A smart phone app (linked to health help now) launched in December 2016 designed to help people decide which urgent care centre to head to for faster treatment for minor injuries.

Outcomes so far

There have been over 160,000 uses and 20,000 downloads up to end of February 2018.  An overall shift of 5.7% of minor attendances from A&E to MIU facilities has been recorded up to the end of January 2018. The WaitLess app is free to download for apple here  (click here) and for android  (click here)